Nursing Care Plan

Medical Surgical C
Student Name: Vi Tran

Patient Data:

Pt. initials: ----

Sex: Male
Age: 58 y.o.
Admitting diagnosis(s): bladder cancer
Working Diagnosis/Current Diagnosis: s/p radical cystoprostatectomy and neobladder procedure
Allergies: NKDA
Admission Date: 6/12/20
Date(s) Care Given: 6/22/20
CODE Status: Full
History of Present Illness (HPI): s/p radical cystoprostatectomy & neobladder using distal ileum (6/12); complains of abdominal distension, KUB x-ray
displays ileus (6/14); CT shows retroperitoneal hematoma and dilated bowel loops (6/16); complains of acute abdominal pain with distention and rigidity
(6/19)

ASSESSMENT DATA
Objective Data Subjective Data
Vital signs (0800) ● Y.K. expresses anxiety with PICC line procedure
Temperature 37°C asking, “Will it hurt?” multiple times before procedure.
Heart Rate 88 bpm ● Pt. states he expresses suicidal ideation when he is off
Blood Pressure 166/104 mmHg antidepressants. States, “I want to die” and “I wish I
Respiratory Rate 20 breaths per minute were dead.”
Oxygen Saturation 97% on 2L of O2 NC ● Y.K. states that his abdomen feels better when he
Pain 5/10 in abdomen, pain started with his abdominal distension and is localized passes flatus and each time he has a bowel
to abdomen; pain is acute in nature and is sharp when he turns in bed or movement.
moves; pain is relieved when lying down, when he passes flatus, and when ● Y.K. states he is tired and didn’t get much sleep during
he has bowel movement the night due to his abdominal discomfort.

Physical Assessment (Abnormals)

GI: Abdomen is distended and round. Midline incision from sternum to suprapubic area
approximately 24cm enclosed by staples. Incision is warm, dry, pink, and open to air with no
drainage. Hyperactive bowel sounds present in all 4 quadrants. Upon light palpation, abdomen is
taut, firm, distended, and pt. complains of abdominal discomfort. Passing flatus. 3 uncontrollable,
loose, and brown BM on AM shift 6/22/20; placed on C. difficile precautions.
GU: 18 Fr foley catheter with 300mL of urine output; insertion site is clean, dry, with no signs of
infection. 22 Fr suprapubic catheter with 200mL of urine output; insertion site is dressed with 2
4x4 gauze and an ABD pad. Urostomy on left lower abdomen with 900mL of urine; surrounding
skin is clean, dry, and intact. Total urine output for AM shift 1400mL. Urine is clear and straw-
colored.
Skin (including IV & wounds): 24cm midline incision on abdomen from sternum to suprapubic
area enclosed by staples. Incision is pink, dry, and open to air with no drainage. Urostomy on left
abdomen with collection bag; surrounding skin is clean, dry, and intact. Suprapubic catheter on
right abdomen dressed with 2 4x4 gauze and an ABD pad. JP drain on left abdomen with 30 cc of
serosanguineous drainage and JP drain on right abdomen with 70 cc of serosanguineous
drainage; insertion sites are pink, clean, and dry. PIV 18G right AC; clean, dry, infusing. PICC 5Fr
left upper arm placed 6/22/20 on AM shift; clean, dry, infusing.
Psychosocial: Flat affect and speaks very little to healthcare staff. Pt. expresses anxiety
regarding new procedures and fears of pain associated with procedures. Pt. states he expresses
suicidal ideation and thoughts when he is off anti-depressant medication, “I wish I were dead,”
and “I want to die.”

Relevant Labs
WBC: 12.28 ×10 9 /L (HIGH)
Blood glucose: 137 mg/dL (HIGH)

Relevant Medications
acetaminophen IV 1000 mg IV q8 hours for pain
HYDROmorphone PCA syringe 10mg/50mL (0.2mg/mL) IV continuous for pain
lidocaine 2g in dextrose 5% 250mL drip RTU 7.5 mL/hr IV continuous for pain
methocarbamol 1000 mg in sodium chloride 0.9% 100 mL IVPB q8 hours for pain
 Height: 176 cm Weight: 77 kg BMI: 25 kg/cm2 (overweight)
Neuro: AOx4. Speech is clear. Aware of appropriate safety precautions. Normocephalic and facial symmetry intact. Positive PERRLA. EOM intact. No
nystagmus. Sensation intact to light touch in all extremities.
Respiratory: 2L O2 via nasal cannula. Chest rise symmetrical, RR even, no visible or apparent distress. No use of accessory muscles. No nasal flaring. AP/T
diameter ratio 1:2. Upon palpation, no palpable masses or lesions and no pain. Breath sounds clear & bilateral in both lobes. No audible wheezing or
adventitious sounds. Coughs are productive.
Cardiac: S1 & S2 present. No audible murmurs, gallops, or rubs present. No JVD at HOB 30°. Carotid pulses present +2 bilaterally. Brachial pulses present +2
bilaterally. Radial pulses +2 bilaterally. Capillary refill time less than 3 seconds bilaterally. Femoral pulses present +2 bilaterally. Dorsal pedal pulses present +2
bilaterally. Posterior tibialis pulses present +2 bilaterally. HR 88 bpm. BP 166/104 mmHg (Stage 2 Hypertension). EKG interpretation: normal sinus rhythm.
GI: Abdomen is distended and round. No visible hernias, lesions, or masses. Midline incision from sternum to suprapubic area approximately 24cm enclosed by
staples. Incision is warm, dry, pink, and open to air with no drainage. Hyperactive bowel sounds present in all 4 quadrants. Upon light palpation, abdomen is
taut, firm, distended, and pt. complains of abdominal discomfort. Passing flatus. 3 uncontrollable, loose, and brown BM on AM shift 6/22/20; placed on C. difficile
precautions. Nasogastric tube in the right nare connected to low intermittent suction; 75cc of dark green drainage in AM shift.
GU: 18 Fr foley catheter with 300mL of urine output; insertion site is clean, dry, with no signs of infection. 22 Fr suprapubic catheter with 200mL of urine output;
insertion site is dressed with 2 4x4 gauze and an ABD pad. Urostomy on left lower abdomen with 900mL of urine; surrounding skin is clean, dry, and intact. Total
urine output for AM shift 1400mL. Urine is clear and straw-colored.
Musculoskeletal: No visible deformities to any joints. Full ROM to shoulders, elbows, wrists, hands, fingers bilaterally. Active and full ROM of ankle and toes
bilaterally with no visible deformities. Hand grips strong and equal bilaterally. BUE 5/5. BLE 4/5. BMAT 3; minimal assistance required. Uses a walker to
ambulate. Morse fall scale 45; standard fall precautions.
Skin (including IV & wounds): 24cm midline incision on abdomen from sternum to suprapubic area enclosed by staples. Incision is pink, dry, and open to air
with no drainage. Urostomy on left abdomen with collection bag; surrounding skin is clean, dry, and intact. Suprapubic catheter on right abdomen dressed with 2
4x4 gauze and an ABD pad. JP drain on left abdomen with 30 cc of serosanguineous drainage and JP drain on right abdomen with 70 cc of serosanguineous
drainage; insertion sites are pink, clean, and dry. PIV 18G right AC; clean, dry, infusing. PICC 5Fr left upper arm; clean, dry, infusing. PIV 22G anterior left wrist
d/c due to infiltration. PIV 22G anterior right forearm d/c due to infiltration. PIV 22G anterior left proximal forearm d/c due to PICC placed on the left upper arm.
Psychosocial: Flat affect and speaks very little to healthcare staff. Pt. expresses anxiety regarding new procedures and fears of pain associated with
procedures. Pt. states he expresses suicidal ideation and thoughts when he is off anti-depressant medication, “I wish I were dead,” and “I want to die.”

IV Lines (ie, Peripheral, PICC, Central Line, PA Catheter, etc)

IV Site Type of Access Status (ie, capped, IV infusing, etc.)
Right antecubital Double lumen peripheral IV 18G Infusing ampicillin 1g in sodium chloride 0.9% 50mL
IVPB 100mL/hr, hydromorphone PCA syringe
10mg/50mL (0.2 mg/mL), sodium chloride 0.9% IV
soln 10 mL/hr prn PCA therapy
Left upper arm Double lumen PICC 5Fr PPN adult 83.33 mL/hr continuous, acetaminophen IV
1000 mg IV 100mL at 400mL/hr
Anterior left wrist Single lumen peripheral IV 22G Discontinued d/t infiltration
Anterior right forearm Single lumen peripheral IV 22G Discontinued d/t infiltration
Left proximal forearm Single lumen peripheral IV 22G Discontinued d/t PICC line placed on left upper arm

Past Medical & Surgical History: bladder cancer, bladder tumor, hypertension, lung surgery, bladder surgery
Social History: Korean speaking; understands basic conversation in English. Lives with wife, adult son, and adult daughter in a home/apartment. His family is
his main support system; sister is very involved in care & visited during AM shift to provide assistance with daily care and ambulation. Religious; Christian.

Pathophysiology of Primary Problem(s)

Bladder tumor & bladder cancer: Y.K. presented with a bladder tumor and was diagnosed with bladder cancer in October 2019. Uroepithelial cells form the
tumor and may have either a papillary growth pattern or a flat appearance. Metastasis usually occurs to lymph nodes, liver, bones, lungs, and adrenal glands.
Signs and symptoms of bladder cancer include the presence of red blood cells in the urine that cannot be seen by the naked eye (microscopic hematuria),
increased voiding frequency, dysuria, nocturia, urgency, urge urinary incontinence, and flank pain due to tumor growth (McCance & Huether, 2019).

Cystoprostatectomy & neobladder: Y.K.’s tumor involved muscle as well, which required a radical cystectomy and prostatectomy. The entire surgery is called
a cystoprostatectomy. A neobladder is a urinary diversion option in the form of an internal urine collection reservoir, which is usually made from the small
intestine and is connected to the urethra (Osborn et al., 2013).

Ileus: Ileus is the lack of peristalsis or movement in the gastrointestinal system which can lead to intestinal obstruction. This often occurs after a surgery due to
the effects of anesthesia and opioids, as they slow gastrointestinal motility. Signs and symptoms of an ileus include a rigid and firm abdomen with hypoactive or
no bowel sounds, and no passage of stool or flatus (Osborn et al., 2013).

Retroperitoneal hematoma: Y.K. presented with retroperitoneal hematoma on 6/16. Retroperitoneal hematoma is defined as bleeding into the retroperitoneal
space and can be hard to detect until there is a lot of blood loss. It can either occur spontaneously or through trauma or associated injuries such as surgery.
Early signs and symptoms may include abdominal, flank, or back pain, as well as nausea and vomiting (Osborn et al., 2013). Diagnosis is normally confirmed
through an abdominal CT scan. Small hematomas in stable patients would be treated by discontinuing anticoagulation and administering blood replacement,
whereas surgical repair is a treatment for larger hematomas (Osborn et al., 2013).
 LABS & DIAGNOSTIC TESTS
Lab/Diagnostic Test Pt’s value (high/low?) Rationale for Abnormal Relevant Nursing Care
Sodium, Na+ 137 mEq/L (WDL) Y.K.’s sodium level is within defined Monitor electrolytes, I/O’s, weight gain or loss, skin
Range: 135-145 mEq/L limits. Low sodium may be caused by turgor, blood pressure. Monitor vital signs and EKG.
certain medications; heart, kidney, and Continue to monitor for s/s of fluid overload or
liver problems; fluid overload; severe dehydration. Infuse isotonic solution such as 0.9%
vomiting and diarrhea, etc. NaCl if volume depletion.
Potassium, K+ 4.1 mmol/L (WDL) Y.K’s potassium level is within defined Monitor electrolytes, I/O’s, weight gain or loss, skin
Range: 3.5-5.1 mmol/L limits. Potassium can be low due to turgor, blood pressure. Monitor vital signs. Monitor
excessive vomiting or diarrhea. EKG for abnormal heart rhythms. Administer
potassium replacement and use potassium sparing
diuretics if labs are low.
Chloride, Cl+ 101 mEq/L (WDL) Y.K.’s chloride lab is within defined Monitor electrolytes, I/O’s, weight gain or loss, skin
Range: 96-106 mEq/L limits. Low chloride can be caused by turgor, blood pressure. Monitor vital signs. Administer
vomiting and diarrhea, which results in chloride replacement to treat hypochloremia.
fluid loss.
Calcium, Ca+ 8.3 mg/dL (LOW) Y.K.’s calcium is low due to the 2 units Monitor calcium levels, signs of hypocalcemia
Range: 8.6-10.3 mg/dL of PRBC transfusions he had on (confusion, memory loss, muscle spasms,
6/18/20. Blood transfusions can cause numbness, tingling in hands, feet, or face) or
hypocalcemia due to the citrate hypercalcemia. Administer calcium replacement if
preservative that is added to the blood. hypocalcemia.
Citrate and calcium bind to make a
complex that is inactive, which lowers
calcium levels.
Blood Urea Nitrogen, BUN 16 mg/dL (WDL) Y.K’s BUN is within defined limits. A Monitor vital signs. Continue to monitor BUN lab
Range: 7-20 mg/dL high BUN can indicate kidney damage, levels and kidney function. Monitor I/O’s, weight, and
dehydration causing low perfusion to skin turgor. Infuse fluids if patient is dehydrated.
kidneys, or heart failure.
Creatinine 0.75 mg/dL (WDL) Y.K. is currently within defined limits. Monitor vital signs. Continue to monitor creatinine
Range: 0.6-1.2 mg/dL Low creatinine levels can be due to levels. Monitor heart function (rate, BP, etc). Monitor
aging, lower muscle mass caused by I/O’s, weight, and skin turgor.
disease, or a diet low in protein. High
serum creatinine can indicate kidney
damage.
Blood Glucose 137 mg/dL (HIGH) Blood glucose can rise due to an Monitor blood glucose levels periodically. Monitor for
Range: 65-100 mg/dL inflammatory response or when the signs and symptoms of hypoglycemia (ie,
body is under stress. Y.K. has just diaphoresis, shakiness, AMS, etc). Patient education
 gone through a very large surgery and regarding Insulin (HumuLIN) being taken and why his
had been diagnosed with bladder blood glucose is high post-operatively. Administer
cancer previous to surgery, thus his corrective insulin for hyperglycemia. Administer
body has been under a lot of stress, dextrose 50% for hypoglycemia.
resulting in his high blood glucose.
White Blood Cell Count, WBC 12.28 ×109/L (HIGH) Infection can cause WBCs to elevate, Monitor WBC. Monitor temperature and signs of
Range: 4.5-11.0 ×109/L as well as stressors such as surgery fever. Monitor vital signs. Monitor respiratory function
since Y.K. had extensive surgery. (rate, depth, effort, etc). Administer antibiotics
(ampicillin) for prophylaxis of UTI and infection.
Hemoglobin, Hgb 10.2 g/dL (LOW) Y.K.’s hemoglobin may be low due to Monitor blood loss (drainage from JP drains and
Range: 13.5-17.5 g/dL blood loss after surgery. wounds). Monitor for signs of anemia. Monitor vital
signs. Administer blood replacement and monitor
response.
Hematocrit, Hct 31.1% (LOW) Y.K.’s hematocrit may be low due to Monitor blood loss (drainage from JP drains and
Range: 41-50% blood loss after surgery. wounds). Monitor for signs of anemia. Monitor
patient’s activity tolerance. Monitor vital signs.
Administer blood replacement and monitor response.
Red Blood Cell Count, RBC 3.47 million cells/mcL (LOW) Y.K.’s RBCs may be low due to blood Monitor blood loss (drainage from JP drains and
Range: 4.7-6.1 million cells/mcL loss after surgery. wounds). Monitor for signs of anemia. Monitor vital
signs. Administer blood replacement and monitor
response.
XR kub portable 6/14/20 NG/OG tip of tube looped Abnormal results would indicate that Ensure that the placement of the NGT is correct
within gastric fundus. the NG tube was placed incorrectly through aspiration of stomach contents and testing
and would require replacement of NGT pH as well as through chest x-ray. Flushing the NGT
before administering anything through before and after medication administration. Making
the nasogastric route. sure to clip or secure the NGT to the patient's gown
to prevent displacement.
CT abd + pelvis wo contrast s/p cystectomy, neobladder. Y.K. was diagnosed with bladder Assess post-op wound frequently for signs of
6/16/20 RP hematoma present in cancer and just had a radical infection. Monitor vital signs (BP, HR, RR, O2,
abdominal cavity. History of cystoprostatectomy and neobladder temperature, pain) for changes. Monitor any drainage
urothelial carcinoma s/p procedure to treat it, which may lead to from wounds and document amount. Monitor JP
cystoprostatectomy, bilateral complications such as retroperitoneal drain output and type of drainage. Provide wound
pelvic node dissection & bleeding. care to promote infection control.
neobladder formation with
postoperative retroperitoneal.
Urinalysis 6/18/29 Yellow Specific gravity can fluctuate Monitor for signs and symptoms of UTI. Monitor
pH 6.5 depending on how dehydrated a electrolytes. Ensure all collection bags and foley
Specific gravity 1.025 patient is. pH can fluctuate if urine bags are placed lower than the patient. Ensure
 Blood dipstick 3+ contains bacteria, kidney failure, adequate hydration & encourage intake of fluids. Do
Bilirubin negative ketone presence, etc. Proteins, routine perineal care for Y.K., making sure to wipe
Glucose negative bilirubin, glucose, and ketones can spill from front to back to avoid UTIs.
Protein 1+ over into the urine, indicating an issue
> 1000 RBC/microliter (HIGH) with filtration (protein), issue with the
5 WBC/microliter liver (bilirubin), or issue with elevated
> 210 RBC/HPF (HIGH) glucose (glucose, ketones). Blood in
Bacteria negative the urine may occur due to a UTI.
RBCs, WBCs, bacteria, or epithelial
cells in the urine may also be caused
by a UTI. In this patient’s case, his
cystoprostatectomy and neobladder
surgery can be a cause of RBC and
protein presence in his urine.
XR chest ap portable 6/22/20 Interval placement of a left PICC line was placed to gain access to Assess the PICC line insertion site for erythema or
upper extremity PICC w/ tip large central veins since Y.K. had so signs of infection. Maintain sterile technique when
terminating in the right atrium. many infiltrated PIVs. Also was placed changing central line dressings to avoid introducing
Enteric tube seen coursing for delivery of TPN and nutrition, as bacteria to the line. Maintain aseptic technique when
below the diaphragm w/ tip well as blood draws. Abnormal administering medications via the PICC line (ie, using
projecting over the gastric placement of PICC would indicate that alcohol wipes for 15 seconds to scrub the port). Flush
body/fundus. Interval the PICC line insertion procedure was before and after medication administration. Cap
extubation. unsuccessful and that nothing is to be PICC line if not in use.
administered via the PICC line.
 EKG (Past EKG strip with interpretation, PR interval, QRS interval, QT interval measurements

Rhythm: Normal sinus rhythm

Rate: 100 bpm
PR interval: 0.16 sec
QRS: .08 sec
QT: .36 sec

MEDICATION LIST
 Name of Drug Class & Mechanism of Action Safe Dosage Dose/ Route/ Frequency Reason Side Effects RN
(Brand & Generic) Range IV Meds (if applicable): Responsibilities/Assessments

OLANZapine C: antipsychotics, mood 5-20 mg/day 5 mg NGT q bedtime Acute therapy of manic neuroleptic malignant Assess mental status
(ZyPREXA, ZyPREXA stabilizers, in the or mixed episodes syndrome, seizures, suicidal (orientation, mood, behavior)
Intramuscular, ZyPREXA thienobenzodiazepine evening associated with bipolar I thoughts, agitation, delirium, throughout medication therapy
Relprevv, ZyPREXA MOA: antagonizes dopamine disorder, depressive dizziness, headache, and monitor for notable
Zydis) and serotonin type 2 in the episodes associated restlessness, sedation, changes in behavior that can
CNS; anticholinergic, with bipolar disorder; tx weakness, amblyopia, indicate the emergence or
antihistamine, and anti-alpha1- of nausea and vomiting rhinitis, orthostatic worsening of suicidal thoughts
adrenergic effects related to highly hypotension, constipation, or depression. Monitor vital
emetogenic dry mouth, increased liver signs, EKG, pulse, and
chemotherapy enzymes, weight loss or respiratory rate before and after
gain, agranulocytosis, drug administration. Assess fluid
reaction with eosinophilia intake and bowel function.
and systemic symptoms Monitor patient for akathisia.
(DRESS), tremor Monitor for neuroleptic
malignant syndrome. Monitor
for DRESS. Monitor CBC
frequently.

HYDROmorphone C: antitussives, opioid agonists 0.2-3 mg/hr PCA syringe Treats moderate to confusion, sedation, Assess patient’s vital signs,
(Dilaudid, Dilaudid-HP, MOA: binds to opiate receptors 10mg/50mL (0.2 mg/mL) severe pain respiratory depression, especially BP, pulse, and
Exalgo, Hydromorph in the CNS, alters the IV continuous hypotension, constipation respirations before medication
Contin, Jurnista) perception and response to therapy and throughout.
painful stimuli while producing
generalized CNS depression

naloxone C: antidote for opioid, opioid 0.02-0.2 mg 0.4 mg/mL inj 0.1 mg Reversal of CNS ventricular arrhythmias, Monitor RR, rhythm, and depth;
(Evzio, Narcan) antagonist q2-3 min until IVP prn opioid overdose depression and HTN, hypotension, nausea, pulse, EKG, BP, and LOC for 3-
MOA: competitively blocks the response respiratory depression vomiting 4 hours after expected peak of
effects of opioids (ie, CNS and obtained; due to suspected opioid blood concentration. Assess
respiratory depression), without repeat q1-2 overdose patient for level of pain after
producing any opioid-like effects hours if administration as it also
needed reverses analgesia. Assess
patient for s/s of opioid
withdrawal. Make sure
resuscitation equipment,
oxygen, vasopressors, and
mechanical ventilation should
be available as needed.

gabapentin C: analgesic adjuncts, 100 mg TID 50mg/mL soln 125mg Traditionally used for suicidal thoughts, confusion, Monitor closely for suicidal
(Gralise, Horizant, therapeutic, anticonvulsants, PO q8 hours (2.5mL) partial seizures, depression, dizziness, thoughts, worsening behavior or
Neurontin) mood stabilizers Titrate postherpetic neuralgia, drowsiness, rhabdomyolysis, depression. Assess the
MOA: may affect transport of weekly by and restless leg ataxia, anaphylaxis, patient’s pain (location,
amino acids across and 300 mg/day syndrome; used for angioedema, multiorgan characteristics, intensity of pain,
stabilize neuronal membranes; up to 900- neuropathic pain and hypersensitivity reactions etc.).
decreased incidence of 2400 mg/day. anxiety for this patient
seizures, decreased Maximum
postherpetic pain, decreased 3600 mg/day.
leg restlessness
 acetaminophen C: antipyretics, nonopioid 325-1000 mg 1000mg IV q8 hours Treats mild pain and agitation, anxiety, headache, Assess overall health status
(Tylenol) analgesic q6 hours fever fatigue, insomnia, dyspnea, and alcohol usage before
MOA: inhibits synthesis of hepatotoxicity, nausea, administration. Assess amount,
prostaglandins that serve as vomiting, hypokalemia, renal frequency, and type of drugs
mediators of pain and fever, failure, neutropenia, taken in patients. Assess for
primarily in the CNS pancytopenia, Stevens- rash throughout therapy.
Johnson syndrome, toxic Assess pain and fever.
epidermal necrolysis, rash

methocarbamol C: skeletal muscle relaxant 1-3 g/day for 1000 mg in sodium Adjunctive treatment of seizures, dizziness, Assess patient’s pain level,
(Robaximol, Robaxin) (centrally acting) not more chloride 0.9% 100 mL muscle spasm drowsiness, light- muscle stiffness, and ROM
MOA: skeletal muscle than 3 days; IVPB q8 hours associated with acute headedness, anorexia, GI through medication therapy.
relaxation as a result of CNS courses may painful musculoskeletal upset, nausea, anaphylaxis Monitor pulse and BP during
depression be repeated conditions (with rest administration. Assess for
after a 48-hr and physical therapy); allergic reactions after
rest used for acute pain for administration and keep
this patient epinephrine and oxygen at
hand. Monitor the IV site for
thrombophlebitis and
extravasation. Monitor renal
function labs.

lidocaine C: anesthetics, anti-arrhythmics 1-4 mg/min of 2g in dextrose 5% 250 Used to treat acute pain seizure, confusion, Monitor ECG continuously, BP
(Xylocaine, Xylocard) MOA: suppresses automaticity continuous mL drip RTU 7.5mL/hr drowsiness, cardiac arrest, and respiratory status
and spontaneous depolarization infusion IV continuous stinging, anaphylaxis frequently throughout
of the ventricles; produces local medication therapy. Monitor for
anesthesia by inhibiting pain intensity throughout
transport of ions in neuronal therapy. Monitor for s/s of
membranes nerve impulses are toxicity (confusion, excitation,
inhibited blurred or double vision, N/V,
ringing of the ears, tremors).
Stop infusion if symptoms of
overdose occur and monitor
patient.

ampicillin C: anti-infectives, 250-500 mg 1g in sodium chloride Treats genitourinary seizures, clostridium difficile- Assess for infection (ie, VS,
(Omnipen, Ampi, aminopenicillins q6 hours 0.9% 50mL IVPB infections and is used associated diarrhea (CDAD), wound appearances, sputum,
Penglobe, Principen) MOA: binds to bacterial cell wall 100mL/hr for prophylaxis of diarrhea, rash, anaphylaxis, urine, stool, WBC) throughout
causing cell death Do not enterococcus UTI serum sickness therapy. Observe for s/s of
exceed 14 anaphylaxis. Monitor for
g/day changes in bowel function such
as diarrhea, abdominal
cramping, fever, and bloody
stools (all s/s of CDAD).

insulin C: antidiabetics, hormones 0.5-1 100 unit/mL sliding scale Control blood glucose hypoglycemia, anaphylaxis, Assess patient for
(HumuLIN R, NovoLIN R) MOA: lowers blood glucose unit/kg/day in SQ prn for correction post-operatively; pt.has hypokalemia, pruritus, hypoglycemia and
through stimulating glucose divided doses high blood glucose d/t erythema, swelling hyperglycemia after
uptake in muscle and fat, inflammatory state administration. Monitor body
inhibits glucose production weight changes. Continue to
monitor blood glucose q6 hours
throughout the medication
regime. Monitor potassium lab
 levels for hypokalemia
throughout therapy.

dextrose 50% C: caloric sources, 20-50 mL of 12.5g IVP prn low blood Used to treat hyperglycemia, local Assess hydration status of
(glucose, Glutose, Insta- carbohydrates 50% solution sugar hypoglycemia; control pain/irritation at IV site due patient receiving medication.
glucose) MOA: provides calories; infused blood glucose to hypertonic solution, Monitor electrolytes. Monitor IV
prevention and treatment of slowly (3 hypokalemia, site for phlebitis and infection.
hypoglycemia mL/min) hypomagnesemia,
hypophosphatemia

fat emulsion 20% C: parenteral nutrition, lipid 1-1.5 2g/mL, 250mL IV Used to provide source increased liver enzymes, Monitor for s/s of
(Intralipid, Liposyn III) calorie sources g/kg/day infusion 20.83mL/hr of calories and essential parenteral nutrition- hypersensitivity or allergic
MOA: provision of calories and once daily fatty acids since patient associated liver disease, reactions. Monitor triglycerides
fatty acids is NPO vomiting, hyperglycemia, and serum fatty acid levels.
anaphylaxis

PPN adult C: parenteral nutrition 900 mOsm/L, 83.33mL/hr IV Used to provide electrolyte imbalances, Monitor vital signs. Monitor
MOA: provision of calories and for no more continuous nutrition and to meet hyperglycemia, blood glucose every 6 hours.
nutrition intravenously than 7-10 weight and energy hypoglycemia, infection, Monitor IV site for phlebitis.
days needs micronutrient deficiencies Monitor for adverse reactions.
Monitor electrolytes.

sodium chloride 0.9% C: mineral and electrolyte 1L 10mL/hr IV prn PCA Fluid replacement, pulmonary edema, edema, Assess patient’s fluid balance
(Slo-Salt) replacement/supplement (containing therapy reconstitute and dilute hypernatremia, (I/O’s, daily weights, edema,
MOA: replacement in deficiency 150 mEq other medications, hypervolemia, hypokalemia, lung sounds) when on therapy.
states and maintains sodium/L), priming fluid extravasation and irritation of Assess patient for s/s of
homeostasis; maintains osmotic should not IV site hyponatremia and
pressure, water distribution, exceed 100 hypernatremia. Monitor serum
fluid and electrolyte balance mL/hr electrolytes.
 NURSING PLAN OF CARE
Nursing Diagnosis Goals Objective Interventions Scientific Rationale Evaluation
1. Acute pain Reach an optimal Achieve pain 1. Conduct and 1. McCaffery et al. (2011) The objective was met.
comfort level and control and relief document a states that determining
r/t abdominal distension be able to AEB maintaining comprehensive pain location, temporal aspects, 1. Y.K. reported 5/10 pain
manage his pain. a pain level of assessment using a pain intensity, characteristics, in his abdominal at the
AEB 3/10 or less and numeric rating scale for and the impact of a patient’s beginning of shift. He
- patient states 5/10 pain in his display little to no pain, as well as pain on function and quality of stated his acute pain
abdomen whenever he turns in facial grimacing OLDCART. Assess life are important in began 6/19/20 with his
bed and when he moves or groaning upon pain level before and determining the underlying abdominal distension. The
movement in bed after administration of cause of pain and effective pain does not radiate and
- upon light palpation, abdomen and during pain medication ways to approach treatment. is localized to his
is taut, firm, distended, and pt. ambulation from (acetaminophen IV, Doing an initial assessment abdomen. The pain is
complains of abdominal 0700 to 1800. methocarbamol, that includes all pain acute in nature and is a
discomfort and pain dilaudid), during vitals information that the client can sharp pain when he turns
(q4 hours), and provide helps in developing in bed or gets up. His pain
- taking medications for pain: whenever working with an individualized pain is relieved when he lies
acetaminophen IV 1000 mg IV patient. management plan for the down, when he passes
q8 hours, HYDROmorphone patient (as cited in Cooney et flatus, and when he has a
PCA syringe 10mg/50mL 2. Administer al., 2019). bowel movement.
(0.2mg/mL) IV continuous, prescribed nonopioid
lidocaine 2g in dextrose 5% analgesic (ie, 1000 mg 2. According to Pasero et al. 2. Y.K. tolerated his
250mL drip RTU 7.5 mL/hr IV IV acetaminophen q8 (2011) and Young & analgesic medication well.
continuous, methocarbamol hours) and ensure the Buvanendran (2012), non- He stated his pain level
1000 mg in sodium chloride patient has access to a opioids are used as first-line was a 3/10 half an hour
0.9% 100 mL IVPB q8 hours button for the PCA analgesics for the treatment of after administration of
dilaudid. mild to moderate acute pain, acetaminophen IV 1000
whereas opioids are used for mg and one push of his
3. Educate and support the treatment of moderate to 0.2 mg/mL of dilaudid from
patient’s use of severe acute pain (as cited in his PCA pump.
nonpharmacological Cooney et al., 2019).
methods in addition to 3. Patient responded well
pharmacological 3. Gelinas & Arbour (2009) to massage and
analgesic approaches and Ignatavicius (2013) relaxation. His sister also
to help control his pain support the use of participated in massaging
before the end of shift nonpharmacological methods the patient to help with
at 1800. Some may such as distraction, imagery, relaxation. He had little to
include distraction, music therapy, simple no facial grimacing after
simple massage, massage, and relaxation as a massaging his head during
relaxation, and complement to the AM care (shampooing his
application of heat and pharmacological treatment of hair and shaving his face).
 cold. pain, although these studies Pain level after care was
also state that more evidence 3/10.
is needed to conclude
effectiveness (as cited in
Cooney et al., 2019).

2. Impaired skin integrity Y.K. will show Y.K.’s incision 1. Assess the site of 1. According to Baranoski & The objective was met.
improved skin and insertion sites skin impairment and Ayello (2012), systematic
r/t surgical incision integrity. of invasive determine the extent of inspection can identify 1. The patient’s incision
devices will show Y.K.’s skin impairment. impending issues early (as wound was clean, pink,
AEB appropriate Inspect and monitor cited in Zulkowski, 2019). dry, open to the air, and
- 24 cm abdominal midline wound healing skin impairment at there was no drainage.
incision from sternum to and will be clean, least once a day for 2. Wound, Ostomy, and There were no changes in
suprapubic area enclosed by dry, and non- color changes, Continence Nurses Society color to his incision and no
staples is pink, dry, and open to infected after redness, swelling, (2010) states that nurses signs of infection of his
air appropriate warmth, pain, or signs should avoid utilizing harsh wound by the end of shift
interventions of infection. cleansing agents, hot water, at 1800.
- suprapubic catheter on right have been extreme friction or force, or
abdomen dressed with 2 4x4 applied by 1800. 2. Utilize normal saline cleansing too frequently to 2. The patient tolerated
gauze and an ABD pad flush with gauze to promote wound healing (as this intervention well.
carefully clean incision cited in Zulkowski, 2019). There was no pain when
- JP drain on left abdomen with as well as JP insertion we washed his incision
30 cc of serosanguineous sites every 4 hours. 3. Vrtis (2013) states that wound with normal saline
drainage and JP drain on right early assessment and and gauze and patted it
abdomen with 70 cc of 3. Teach Y.K. and intervention can help prevent dry using as little friction
serosanguineous drainage; family ways to assess serious problems from as possible. His surgical
insertion sites are pink, clean, and monitor wounds for developing and that health incision as well as his two
and dry. signs and symptoms of care costs can be reduced JP insertion sites on his
infection, with a client specific plan of abdomen were kept clean
complications, and care with education regarding and dry until the end of
healing by the end of wounds (as cited in shift at 1800.
shift. Zulkowski, 2019).
3. Both Y.K. and his sister
were receptive to learning
more about how to monitor
his surgical incisions and
how to prevent infection.
The sister had inquired
about what kind of soap
they can use to wash the
incision and how often to
clean it. The sister was
concerned about the
 pinkness of the incision
site after we had talked
about assessing for
infection but was
reassured that his skin
color surrounding the
incision site had not
changed within the past
day.

3. Diarrhea The patient will Y.K.’s perirectal 1. Assess and treat 1. Wilson et al (2014) and The objective was met.
maintain a clean area will be free hydration status of Shahin & Lohrmann (2015)
r/t treatment regime (use of perineal area free from irritation and patient, evaluate state that the possible cause 1. Y.K. did not exhibit any
prophylactic antibiotics like from irritation. will be kept clean current medications, of diarrhea needs to be signs or symptoms of
ampicillin) and dry obtain a stool assessed and client hydration dehydration. Since he is
throughout shift, specimen since and skin interventions should currently on antibiotic
AEB and the patient infectious etiology is be utilized to prevent therapy (ampicillin) for
- hyperactive bowel sounds will be able to suspected by the end secondary complications of enterococcus UTI
present in all 4 quadrants explain the cause of shift. diarrhea (as cited in Makic & prophylaxis, infectious
of diarrhea and Ackley, 2019). etiology of his diarrhea is
- x3 uncontrollable, loose, and rationale for 2. Thoroughly cleanse suspected. We were not
brown bowel movements on treatment by the and dry the perineal 2. Makic et al (2011) and able to collect a stool
AM shift 6/22/20 end of shift. area daily and as Martin et al (2014) both state specimen by the end of
needed with a gentle that patient care related to C. shift, but we were able to
- placed on C. difficile cleanser and apply skin difficile include contact endorse it to the oncoming
precautions moisture barrier cream isolation, soap and water nurse for night shift.
as needed. Utilize hand washing (alcohol rubs
contact precautions are ineffective), use of 2. Y.K. tolerated this
when caring for Y.K. to disposable equipment, and intervention well. After his
prevent spread of environmental room 3rd loose stool, we placed
infectious diarrhea. decontamination (as cited in him on C. difficile
Makic & Ackley, 2019). precautions which was
3. Teach Y.K. and his Perineal hygiene prevents initially upsetting to him
family about the types secondary complications of because he had been in
of diarrhea that he may diarrhea. the middle of ambulating
encounter as a cancer on the floor of the unit. We
patient and what C. 3. Andreyev et al (2014) had cleansed his perineal
difficile is. Teach what states that diarrhea is a area very well and
the associated signs common complication that changed his linens and
and symptoms are, and causes dehydration, clothes, which he was very
what treatments are electrolyte imbalances, and appreciative of.
available by the end of hospitalization for treatment.
shift. Providing patient education is 3. Both Y.K. and his sister
 important in preventing were initially upset upon
adverse patient outcomes (as learning that he would be
cited in Makic & Ackley, placed on C. difficile
2019). precautions and would be
unable to leave his room.
After teaching them about
the high possibility of it
being C. difficile due to his
antibiotic regime and the
infectious nature of C.
difficile, they understood
and were compliant with
the intervention. They had
full understanding that he
might be placed on more
antibiotics in the event he
is C. difficile positive.

4. Risk for infection Y.K. will remain Y.K.’s infection- 1. Assess for signs of 1. Risi (2009) states that The objective was met.
free from prone sites will be infection such as changes from baseline such
r/t alteration in skin integrity, symptoms of clean, dry, and redness, warmth, as changes in mental status, 1. Y.K. did not exhibit any
invasive procedure infection during exhibit no signs of discharge, and fever, shaking, chills, and changes from baseline.
contact with infection with the increased body hypotension are all indicators His infection-prone sites
AEB health care applied temperature every 4 of sepsis (as cited by were reassessed every 4
- 18 Fr foley catheter, 22 Fr providers. interventions by hours. Pay special Curchoe, 2019). hours whenever vitals
suprapubic catheter, urostomy the end of shift at attention to his were taken. His PICC line
on left lower abdomen 1800. infection-prone sites 2. Coughlan & Healy (2008) and IV sites were both
such as his IV site, states that daily showers and clean and dry. The two JP
- JP drains on both left and PICC line, foley baths can help to reduce insertion sites on his
right abdomen catheter, surgical bacteria on a patient’s skin abdomen were both pink,
incision, and JP drain (as cited by Curchoe, 2019). clean, and dry. The JP
- PICC line placed on left upper insertion sites. drains had
extremity during AM shift 3. Murphy (2014) states that serosanguineous
2. Assist patient in two thirds of surgical wound drainage. The surrounding
- 24 cm abdominal midline meeting hygiene needs infections occur after skin of his suprapubic
incision from sternum to such as handwashing, discharge and utilizing good catheter was also pink,
suprapubic area enclosed by bathing, hair, nail, and hand hygiene is effective in clean, and dry. His
staples perineal care. Perform preventing these surgical incision was
a 2% chlorhexidine postoperative infections (as clean, dry, open to air, and
- relevant labs: elevated WBC gluconate (CHG) wipe cited by Curchoe, 2019). had no drainage.
(12.28 ×109/L); elevated blood down at least once
glucose (137 mg/dL) daily before the end of 2. Y.K. tolerated this
shift. intervention well. While it
 was difficult for him to turn
3. Teach Y.K. and his in bed and move, we were
family about risk able to give him a full bed
factors contributing to bath and a CHG wipe
surgical wound down. He expressed
infections, catheter gratitude after we assisted
associated UTIs, him in meeting his hygiene
central catheter needs (bed bath, washed
infections, as well as hair, shaved, perineal
the importance of strict care).
hand hygiene in
preventing infections 3. Both Y.K. and his sister
by the end of shift. were receptive to patient
education regarding
stricter hand hygiene to
prevent infection,
especially after the patient
education about C.
difficile. The sister
practiced frequent hand
hygiene when she helped
with the patient’s daily
care.

5. Risk for suicide (approved Y.K. will not harm Y.K. will not 1. Assess, report, and 1. American Psychiatric The objective was met.
to use 2nd ‘risk for’ by himself. obtain access to document any changes Nurses Association (2015)
Professor Totten 6/29/20 for harmful objects in Y.K.’s mood or states that suicidal ideation is 1. Y.K.’s mood and
psychosocial NANDA) and will not harm behavior that may not continuous, and it can behavior did not change
himself increase his suicide increase or decrease during shift other than him
r/t physical illness, reports throughout shift risk periodically depending on negative stating, “I want to die.”
desire to die 0700-1800. throughout shift. thinking and exposure to Throughout the shift he
Assess suicidal risk at stressors. It is important to had a flat affect and rarely
AEB least once during daily notify the healthcare team of talked to the healthcare
- states he expresses suicidal and as needed. any changes to prepare for staff.
ideation when he is off suicidal behavior (as cited by
antidepressants; states, “I want 2. Assign Y.K. a 1-on-1 Patusky, 2019). 2. Y.K. was assigned a 1-
to die” and “I wish I were dead” sitter that can on-1 care partner to
supervise him to 2. Mills et al (2008) mentions supervise him the
- patient has a flat affect and ensure that he does that close observation of the following shift 6/23/20. He
speaks very little to healthcare not harm himself. patient is necessary for safety tolerated this intervention
staff (as cited by Patusky, 2019). well and appreciated the
3. Provide patient 1-on-1 attention. He did
- patient expresses anxiety education to Y.K. and 3. Bowers & Park (2001) not harm himself
regarding new procedures and his family about the states that suicide precautions throughout the shift.
fear of pain associated with purpose of suicide might be seen as restrictive
procedures precautions and safety and that patients have 3. We were able to explain
issues. Refer Y.K. to reported feeling a loss of to Y.K. and his sister that
psychiatry for treatment privacy as distressing (as he would have 1-on-1 care
and management of cited by Patusky, 2019). with a care partner to keep
illness or symptoms Tarrier et al (2008) states that him company and to take
that may cause his research shows that cognitive suicide precautions and
suicidal ideation. behavior therapy is highly measures. Both parties
effective in reducing suicidal were receptive to this. We
behavior (as cited by Patusky, were not able to refer Y.K.
2019). to psychiatry for cognitive
therapy, but I believe this
would have been
beneficial to Y.K. in finding
the root cause of his
suicidal ideation and
treating it.
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